Citation Nr: 0629540
Decision Date: 09/18/06 Archive Date: 09/26/06
DOCKET NO. 96-12 837 ) DATE
)
)
On appeal from the
Department of Veterans Affairs (VA) Regional Office and
Insurance Center (RO) in Philadelphia, Pennsylvania
THE ISSUE
Entitlement to service connection for irritable bowel
syndrome (IBS).
WITNESSES AT HEARING ON APPEAL
Appellant and Spouse
ATTORNEY FOR THE BOARD
M. Sorisio, Associate Counsel
INTRODUCTION
The appellant is a veteran who served on active duty from
October 1992 to April 1995. This matter is before the Board
of Veterans' Appeals (Board) on appeal from a September 1995
rating decision of the Philadelphia RO. In November 2000, a
Travel Board hearing was held before the undersigned. A
transcript of the hearing is of record. The case was
previously before the Board in March 2001 and July 2003, when
it was remanded for further development of the evidence. In
August 2005, the Board referred the case to the Veterans
Health Administration (VHA) for an advisory medical opinion.
FINDING OF FACT
The veteran is reasonably shown to have IBS that is related
to service.
CONCLUSION OF LAW
Service connection for IBS is warranted. 38 U.S.C.A.
§§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304.
REASONS AND BASES FOR FINDING AND CONCLUSION
A. Veterans Claims Assistance Act of 2000
The Veterans Claims Assistance Act of 2000 (VCAA) describes
VA's duty to notify and assist claimants in substantiating a
claim for VA benefits. See 38 U.S.C.A. §§ 5100, 5102, 5103,
5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159,
3.326(a). The VCAA applies to the instant claim.
Upon receipt of a complete or substantially complete
application for benefits, VA is required to notify the
claimant of any information, and any medical or lay evidence,
that is necessary to substantiate the claim. 38 U.S.C.A.
§ 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi,
16 Vet. App. 183 (2002). Proper VCAA notice must inform the
claimant of any information and evidence not of record (1)
that is necessary to substantiate the claim; (2) that VA will
seek to provide; (3) that the claimant is expected to
provide; and (4) must ask the claimant to provide any
evidence in his or her possession that pertains to the claim.
38 C.F.R. § 3.159(b)(1). VCAA notice should be provided to a
claimant before the initial unfavorable agency of original
jurisdiction decision on a claim. Pelegrini v. Principi, 18
Vet. App. 112 (2004).
Since the determination below constitutes a full grant of the
claim being addressed, there is no reason to belabor the
impact of the VCAA on this matter, since any error in notice
content or timing is harmless.
B. Factual Background
Service medical records (SMRs) show the veteran had her
gallbladder removed in June 1993 while stationed in Korea.
After the surgery, the veteran continued to complain of and
seek treatment for abdominal pain and nausea. SMRs from
September, October, and November 1993 provide impressions of
"probable" IBS. Several gastrointestinal (GI) studies,
such as a small bowel follow through, were completed; the
results of these tests were normal. The plan in November
1993 was to schedule an endoscopic retrograde
cholangiopancreatography (ERCP), however, SMRs do not reflect
this test was ever completed. The veteran subsequently
returned to the United States where she underwent further
medical testing; treatment notations indicate her picture was
compatible with IBS. Psychiatric testing in February 1994
resulted in a diagnosis of somatoform disorder, rule out
depression. IBS was not noted on August 1994 periodic
physical examination. September 1994 tests results from
Walter Reed Army Medical Center show delayed gastric emptying
to a mild degree. The September 1994 medical board
evaluation provided an Axis I diagnosis of "undifferentiated
somatoform disorder manifested by greater than six month
history of gastrointestinal complaints with a negative
organic workup treated and unimproved." The medical board
concluded the veteran was medically unacceptable. DD Form
214 indicates the veteran was separated from service in April
1995 because of physical disability.
May 1995 to March 2003 VA treatment and examination records
show the veteran continued to complain of abdominal pain,
nausea, and diarrhea.
An October 1995 VA ultrasound of the abdomen was normal,
except for the absent gallbladder.
In conjunction with an April 1996 VA examination, June 1996
VA abdomen ultrasound and upper GI series results were
normal. Barium enema showed fecal artifacts, but was
otherwise normal. In December 1997, the examiner
interpreting these results provided diagnoses of "chronic GI
disorder, apparently psychosomatic" and anorexia nervosa.
He noted that he concluded the GI disorder was psychosomatic
because there was no active pathology in the abdomen. The
veteran linked her symptoms to her gallbladder removal, but
the examiner stated that type of surgery did not normally
"give this pathology."
At the November 2000 hearing, the veteran testified that she
continued to suffer from abdominal pain "pretty much on a
daily basis." If she ate something that did not agree with
her, she vomited or had diarrhea. When she ate foods that
did not cause those problems she had infrequent bowel
movements (about three a month). She controlled the problem
by restricting her diet, and for several years only ate baby
food. As a result of her dietary restrictions, she lost a
lot of weight. She testified that she became very tired and
weak and had difficulty maintaining employment because her
illness caused her to take a lot of time off from work,
resulting in her having three or four jobs over the last
couple of years. She also stated her illness caused her
"more or less [to] become an introvert."
On February 2003 VA examination, the examiner thoroughly
reviewed the veteran's claims file. The veteran provided a
history of continuing to suffer from diarrhea and abdominal
pain since her discharge from service. She develops
abdominal pain in the lower and right upper quadrant of the
abdomen and has diarrhea within a half-hour of eating.
Acidic, greasy, or spicy foods, milk, and meats cause her to
have cramps and diarrhea. Cheese does not cause these
problems and lactose tolerance testing during service
concluded she was not lactose intolerant. She averages three
to five bowel movements a day; has runny and watery stools
that do not contain undigested foods, but sometimes contain
grease and usually contain a lot of mucus. She occasionally
notices blood in her stools. The examiner noted there was no
history of melena. She also reported she periodically
suffers from fever and chills. On physical examination, the
mid lower abdomen and right upper quadrant were tender to
palpation. Bowel sounds were "slightly hyperactive." The
abdomen was soft and there were no masses of
hepatosplenomegaly. Rectal examination revealed external
skin tags; some formed stool in the rectal vault; no rectal
masses; and tenderness upon examination that caused
discomfort in the mid-abdomen anteriorly. The examiner's
plan was to complete an upper GI series, small bowel follow
through, and laboratory studies before providing a diagnosis
and etiology opinion.
A February 2003 note from a physician's assistant (PA),
written in conjunction with the above described VA
examination, reflects the PA reviewed the veteran's records
and the VA examiner's examination report. She noted that
several tests should be performed, to include a lactose
intolerance test, an ERCP, and a sphincter of Oddi manometry,
to rule out certain disorders, such as lactose intolerance, a
sphincter of Oddi dysfunction, and celiac disease. She
concluded that "the most likely explanation for her chronic
symptoms and nondiagnostic workup is in fact [IBS], which
falls under the category of somatoform disorders. The
syndrome has its basis in stress, tension, and anxiety, and
although I think further testing might be indicated, I think
there is a high likelihood further testing will not result in
significant findings." A draft version of this note is
signed by the VA examiner, indicating approval of the PA's
treatment plan and opinions.
March 2003 VA upper GI series and small bowel follow through
results were normal. An addendum to the VA examination
report (by the February 2003 PA, approved by the VA examiner)
states that lab studies were normal and unrevealing. The
veteran did not provide stool samples. The addendum notes a
gastroenterology evaluation by Dr. G. was reviewed. The PA
was unable to get in touch with the veteran, so additional
tests suggested by Dr. G. were not completed. Since these
tests were not done, the PA provided a diagnosis of
somatoform disorder based on the following rationale:
At this juncture, it can be stated that there is
no objective evidence to support a diagnosis of
some type of organic gastrointestinal disorder.
It is more likely than not that no organic disease
would have been uncovered to explain her prolonged
symptoms had additional tests been done and at
this point in time no such disorder has been
uncovered with the testing done to date.
Therefore, the diagnosis would remain the same
somatoform disorder (irritable bowel syndrome). I
also direct you to the conclusion given by Dr.
[G.], the consulting gastroenterologist, who felt
that further testing would be not likely to result
in any significant findings.
In August 2005, the Board referred the case for a VHA
advisory opinion requesting responses to two questions: 1)
Is IBS an "organic" gastrointestinal disorder or a
"somatoform" disorder?; and 2) If IBS is an "organic"
gastrointestinal disorder, is it related to her military
service (to include the diagnoses of "probable" IBS in
service)?
In September 2005, a VA gastroenterologist reviewed the
veteran's claims file and noted that the veteran has been
given several presumptive diagnoses of IBS, but had not
received a definitive diagnosis. She indicated that the
Rome or Manning criteria used to make a definitive diagnosis
of IBS could not be applied, because specific data regarding
the consistency and frequency of stool, presence or absence
of mucus, and relationship of the veteran's pain to
defecation were not in the claims file. She stated that
"[i]n order to make the diagnosis of IBS all other
etiologies must be ruled out and certain clinical symptoms
must exist." The gastroenterologist provided the following
explanation regarding the disorder of IBS:
IBS is a motor disorder clinically consisting of
altered bowel habits, abdominal pain, and the
absence of any detectable organic pathology. We
classify IBS as a functional bowel disorder. In
IBS we believe it is an illness albeit with no
organic pathology that can be diagnosed with
current methods. IBS is defined by clinical
criteria. Two different criteria, Rome and
Manning[,] have been described to make the
diagnosis of IBS. IBS is multifactorial in
etiology and pathophysiology and frequently has a
psychological component most often depression,
however it is a functional bowel disease not a
psychiatric disease. IBS is a syndrome
manifesting disordered motor activity of the
colon and rectum and often is only part of a more
generalized disorder of the gut. IBS is a true
medical disorder with significant impact on those
afflicted with [it] in regard to symptom
severity, disability, and impaired quality of
life. . . . Although IBS patients show enhanced
stress responsiveness, and more severe and
prolonged impairment of bowel function related to
various inciting factors, specific psychological
factors are not characteristic of the disorder;
they are not considered in the diagnosis.
The VHA gastroenterologist did not provide an etiology
opinion.
C. Legal Criteria
In order to establish service connection for a claimed
disability, there must be: (1) medical evidence of a current
disability; (2) medical, or in certain circumstances, lay
evidence of in-service incurrence or aggravation of a disease
or injury; and (3) medical evidence of a nexus between the
claimed in-service disease or injury and the current
disability. Hickson v. West, 12 Vet. App. 247, 253 (1999).
Disorders diagnosed after discharge will still be service
connected if all the evidence, including that pertinent to
service, establishes that the disease was incurred in
service. 38 C.F.R. § 3.303(d); see also Combee v. Brown, 34
F.3d 1039, 1043 (Fed. Cir. 1994). The determination as to
whether these requirements are met is based on an analysis of
all the evidence of record and the evaluation of its
credibility and probative value. Baldwin v. West, 13 Vet.
App. 1 (1999); 38 C.F.R. § 3.303(a).
When there is an approximate balance of positive and negative
evidence regarding the merits of an issue material to the
determination of the matter, the benefit of the doubt in
resolving each such issue shall be given to the claimant.
38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102.
When all of the evidence is assembled, VA is responsible for
determining whether the evidence supports the claim or is in
relative equipoise, with the veteran prevailing in either
event, or whether a fair preponderance of the evidence is
against the claim, in which case the claim is denied.
Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990).
D. Analysis
The record shows the veteran received treatment for abdominal
pain, nausea, and diarrhea during service; SMRs also include
several notations of "probable" diagnoses of IBS. VA
treatment records and history provided by the veteran show
that the symptoms of abdominal pain, nausea, and diarrhea
have persisted since her discharge from service. She has
received many diagnoses of IBS as psychosomatic and
somatoform disorders, including a December 1997 VA examiner's
diagnosis of "chronic GI disorder, apparently
psychosomatic" and a February and March 2003 VA examiner
approved diagnosis of "somatoform disorder (irritable bowel
syndrome)". The characterizations of these diagnoses as
somatoform disorders were because all clinical test results
were normal and, even though all necessary testing had not
been completed, it was not believed further testing would
uncover an organic disorder.
In September 2005, a VHA specialist noted that while
presumptive diagnoses of IBS had been provided, necessary
tests had not been completed to rule out other potential
diagnoses. She stated she was unable to apply the Rome or
Manning criteria to make a conclusive diagnosis of IBS
because pertinent questions, such as the consistency and
frequency of stool, presence or absence of mucus, and
relationship of abdominal pain to defecation, had not been
asked. However, it is noteworthy that on February 2003 VA
examination, the veteran reported she averaged three to five
bowel movements a day, had runny and watery stools that
usually contained a lot of mucus, and would get abdominal
pain and diarrhea after eating certain foods. These findings
specifically correspond to the Rome criteria mentioned by the
VHA gastroenterologist. The March 2003 VA opinion that no
organic pathology had been found by tests previously
completed and that it was unlikely further testing would
uncover an organic disease aligns with the VHA
gastroenterologist's explanation that there is "an absence
of any detectable organic pathology" with the disorder of
IBS.
In evaluating the entirety of the above cited evidence, the
Board finds that there is an approximate balance of the
evidence for and against the veteran's claim. Resolving
reasonable doubt in her favor as the law requires in such
circumstances, the Board concludes that service connection
for IBS is warranted.
ORDER
Service connection for IBS is granted.
____________________________________________
George R. Senyk
Veterans Law Judge, Board of Veterans' Appeals
Department of Veterans Affairs